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Share the Article has launched a new column called ‘VaerKaanal’ (Finding the Roots) in which a problem is taken up and discussed in-depth with an expert to understand the roots of the issue. In this first episode of ‘VaerKaanal’ vascular surgeon J. Amolarpavanathan explains the growing global concerns over hospital acquired infection (HAI).

In September this year, the British medical journal, Lancet warned that chances and percentage of cases of hospital acquired infection,or HAI, spreading from India are high. We turned to Dr.Amolarpavanathan to explain HAI and its ramifications which has set off alarm across the world.

Dr.Amolarpavanathan traced the problem back in time and began by comparing hospitals in the past and at present.  About 100 or even 50 years ago, he pointed out, the number of hospitals was very limited. The hospitals, constructed on sprawling grounds then, did not have air-conditioned wards, and natural air flowed freely through the buildings.

About 50 or 100 years ago, the number of hospitals was very limited. They had been constructed on sprawling grounds in areas endowed with natural air. The number of patients visiting hospitals was also fewer.  

While the number of patients visiting hospitals was fewer, the inpatients did not stay long in hospitals either. At best they would stay for treatment only for a couple of days. Either they would be discharged or would breathe their last in the wards by then. And finally, the space between beds in hospitals was well-maintained so there would be no chance of infection spreading.

However, in present times, the number of hospitals is staggering. Owing to the astronomical development of medicine, increasing diseases and swelling number of patients, we have a countless number of hospitals which all have centralized AC systems, says Dr.Amolarpavanathan.

Further, there’s no hospital without an ICU (intensive care unit). Every hospital has around 10 to 15 per cent and even 20 per cent of ICU beds.  The ICUs were created because of an upswing in the critical illnesses and also because the units would fetch the hospitals more revenue.

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Prolonged stay
As a result, it is common now for critically ill patients to stay in hospitals for a long time — for 30 or 40 days — and be on ventilators. Such patients are administered heavy doses of antibiotics which however, lose their efficacy over time as the viruses that the drugs are meant to tackle either become resistant to the medicine or spread through the hospital infecting other patients and staff. This situation has led to the present crisis of hospital acquired infection (HAI).

“I have read … probably in Lancet that in the US, HAI has become a major cause of deaths,” Dr.Amolarpavanathan said.

A patient may go to a hospital to treat a fracture in the leg or hand fracture but may contract an infection in the hospital, he explained adding ironically, going to the hospital for curing diseases could make you more ill!

Underlining this message of HAI, Dr.Amolarpavanathan advised people: except during emergencies, don’t go to a hospital for minor problems.

Heavy doses of antibiotics at one point of time refuse to work as the viruses that the antibiotics intend to tackle either become resistant to the medicine or get out of the patient’s body and start spreading in the hospital itself, infecting others; This is where today’s major issue of hospital acquired infection (HAI) arises

Elaborating on the alarming problem, he said not only patients but also doctors, nurses and other hospital personnel were extremely susceptible to the HAI. Spending most part of the day and meeting patients back to back, has meant that most physicians run the risk of contracting infections despite precautions.

Dr.Amolarpavanathan warned that there are few medicines to combat HAI and even if it’s available, it is costly.

Asked about the symptoms of HAI and how one could distinguish routine infections from HAI, Dr.  Amolarpavanathan said a patient with fractures may visit a hospital and injured limb may be placed in a cast during his stay in the hospital.  However, during this time, the patient may contract lung infection and doctors will begin treating the fever. So while the fracture may have set, the fever may not subside. A diagnosis by the doctor / hospital may reveal HAI. Then the doctors accordingly change their strategies and administer different kinds of medicine to the patient.

Vulnerable cohort
In fact, HAI targets pre-term babies, cancer patients undergoing chemotherapy and having reduced immunity, elderly patients having lifestyle disease such as diabetes, hypertension etc. admitted in the ICUs and even patients breathing with ventilator support.  There is also a disease caused by the ventilator which is known as VAP (ventilator acquired pneumonia), Dr.Amolarpavanathan remarked.  HAI will manifest itself in symptoms such as breathlessness, wheezing, uncontrolled diarrhoea and even brain fever.

Building it right
Given that air-conditioners in closed rooms are a major source of HAI and the Lancet reports that HAIs spread from tertiary hospitals, Dr. Amolarpavanathan said a hospital must ideally be located in an environment with free, naturally flowing air. But, he conceded that this was not possible amid the growing congestion. Moreover, computers and air-conditioners have become part and parcel of hospitals. The AC units circulate cool air and computers are susceptible to dust pollution. They must periodically be cleaned and maintained, he said, adding that there are HEPA filters for air-conditioners. But whether the filters can keep all kinds of viruses from spreading in hospitals is a moot point. Besides, HEPA filters are quite expensive.

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Asked if any country had discovered ways to deal with HAI and whether there were any SoPs to tackle the menace, Dr. Amolarpavanathan said generally the problem starts with hospital architecture, particularly the ICU unit architecture.  Ideally, no outsider is allowed into an ICU and antibiotics are administered only to patients who really need them. Not all patients are admitted in ICUs unless there are strong reasons for it. Moreover, one-to-one nursing is adopted in the ICUs — that is, a nurse attending on a particular patient should not move to another in order to avoid infection.  As part of precautionary methods, hospitals should strictly follow the procedure of changing not only bed-sheets but also mattresses, he said.

On legal guidelines for hospital architecture, as for schools and colleges, Dr. Amolarpavanathan replied, “Yes of course!”

Elaborating, he said there are several rules and regulations such as three-foot spacing between two beds, how an operation theatre should be constructed and how the personnel should function in hospital premises…. There are several architectural norms and protocols on movement of people. As the US has the Joint Commission International on patients’ safety and healthcare functions, India has the National Accreditation Board for Hospitals and Healthcare Providers. They come and inspect hospitals to check whether they are complying with norms and protocols on architecture of hospital, bed arrangement, treatment methods, waste disposal etc. The evaluation team functions as a quality control mechanism. Accreditation is given to hospitals only after this kind of evaluation based on several parameters.

As the US has the Joint Commission International on patients’ safety and healthcare functions, India has the National Accreditation Board for Hospitals and Healthcare Providers

“I do not know if the American model of hospital infrastructure is possible in India,” he said but added that “We have to be also on vigil against the HAI, adhering to the rules and regulations to prevent it.”

On whether nurses were given special training to deal with HAI, Dr.Amolarpavanathan replied in the affirmative, adding that training and classes are regularly conducted for nurses. But it is an ongoing process. Nurses come and go but the training session goes on forever, he quipped.

Are there precautionary measures for HAI such as wearing of masks, made mandatory during the corona virus epidemic?

Dr.Amolarpavanathan there was no need for that pointing out that HAI is no corona even though 10 to 15 per cent of infections are acquired in hospitals. There are diagnostic methods, tests and antibiotics for HAI and there was no need to panic.

That said, Dr.Amolarpavanathan ended on a note of caution, saying: “Don’t go to a hospital unless there is a strong need.”

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